Editor’s Note: This is the third installment of Curbside Consult, written by two Group for the Advancement of Psychiatry (GAP) committees – the Committee on Family Psychiatry and the Committee on Cultural Psychiatry.
Erica is a 19-year-old woman from an ethnically mixed background. Her father is an African American retired U.S. military officer who met her mother while he was stationed in Japan, where her mother was born and raised. Erica lived in Japan until she was 8, when the family moved to Seattle, and her father began a new career in a large company.
At age 10, she began to have episodes during which she felt her heart racing, was short of breath, and was diaphoretic. These episodes often took place when the family went out to large public spaces, like a shopping mall, and she would be separated from her parents. They increased in frequency until she was taken to a pediatrician and saw a counselor. Her panic symptoms gradually disappeared during high school, but since starting college and moving away from home, she has felt lost in her environment, and feels as though no one understands her background and upbringing. For example, she abruptly left the first college party she attended, feeling that “everybody had met everybody already and nobody noticed me; maybe they don’t like the way I look.” She has had a return of panic episodes that are now more frequent, coming on without warning, and they have begun to wake her from sleep.
Discussion
Incorporating a family and culture lens to the case can improve assessment and treatment planning. Given the brevity of the case description, many of our recommendations focus on obtaining additional information. It is also important to rule out any medical conditions that could be causing her symptoms. Finally, since great heterogeneity exists within every culture, the clinician should investigate the meanings associated with specific cultural backgrounds for each person to avoid stereotyping that would interfere with an accurate assessment and treatment plan.
Possible cultural conflicts
Although the identified patient in this case is the young woman, the number of culture- and family-related stresses experienced by each member of her family cannot be overstated. The family is truly multicultural, in every sense of the word. Many Americans associate the word “culture” with the influence of race, ethnicity, and country of origin, but the term encompasses many other aspects of the family’s background as well, including the father’s immersion in military culture as an officer of color, the culture of American ex-pats in Japan and of Japanese immigrants to the West Coast of the United States, multiracial children’s adaptations to Japanese and state schools, and U.S. corporate culture. Every member of the family has therefore had to adapt to many cultural transitions. All of these moves require new relationships with the dominant culture and immediate community, which increases stresses within the family as well as between the family and the broader society in which they live. Conflict between the parents increases vigilance and anxiety in children, and since Erica does not have siblings, the likelihood of being caught in a conflict between both parent would be high.
One adaptation that the family has undergone involves negotiating variations in “individualism” – a cultural ideology that prizes the role and desires of the individual over that of the group – and “collectivism” – in which the values and expectations of the social group are prioritized. Each society (for example, urban Japan) and social group (for example, the U.S. military) is characterized by a combination of individualistic and collectivistic traits, though a certain cultural flavor tends to predominate.
If Erica’s mother’s family of origin in Japan was very traditionally collectivistic, she may have experienced a difficult cultural shift when she moved to the United States, which tends to value more individualistic self-presentation. This conflict may have affected Erica’s development, particularly if it were an area of difficulty during her mother’s adaptation to her move or a potential sore spot in the father’s relationship with his wife. It would be good to explore to what extent the mother embraced her move to her new home in Seattle, and whether she also tried to keep her culture of origin alive in the family, while she negotiated her acculturation to U.S. society. In a cosmopolitan city like Seattle with a growing Asian population, this may be easier than in past years, but still might require a great deal of effort. The mother’s adaptation seems an important topic for further assessment, including discovering whether she found work in the United States, if she created new social networks, or whether she remained isolated with her husband and her daughter.
As to the father, if he grew up in a U.S. community that relied on a direct communication style that valued individual assertion as a component of identity and self-esteem, he may have seen his wife’s approach to communication as too reserved, private, or other-directed, especially if her English proficiency or his Japanese fluency was limited. These conflicts may have affected Erica’s sense of self but must be evaluated directly rather than assumed; each parent’s fluency and communication style are fruitful questions to explore. It is possible that conflicts in this area may have interfered with Erica’s incorporation of either parent as a role model for her as a young woman in contemporary U.S. society, threatening her sense of self and leading to anxiety symptoms.
Another area of potential stress for the family involves the experience of discrimination tied to racism or other forms of prejudice. Each family member is vulnerable in this area in his/her own right, given the potential mismatches between their racial/ethnic background and the sometimes intolerant views of dominant social groupings in their societies of origin or their societies of migration. Erica may be most vulnerable in this regard, in light of her dual minority background. The clinician should assess to what extent either or both families of origin may be unhappy about the marriage and biracial child and the possible resulting impact on Erica’s sense of herself. Does she feel more attracted to one aspect of her background? In terms of Erica’s developing identity, it is important to understand whether the family maintains one culture as the family of heritage or works toward developing a multicultural identity. If neither parent can completely identify with Erica, they must work with her to find a way to mesh both cultures. If they do not, she may feel that she has to choose her presentation to the world as African American, Japanese, multiracial, or “post racial.” This may complicate her sense of connection to one or both parents. To some extent this may be affected by which parent she most takes after physically or to which side of the extended family she feels closer. The clinician should consider all these issues in conducting a culturally competent assessment and family-based intervention.
Development context of Erica’s symptom course
Since Erica was asymptomatic during the first 2 years after the move to the United States, it may be possible to assume that early adaptation went reasonably well. The onset of symptoms at age 10 may stem from numerous causes. Biologically, she may have been in prepuberty, which can increase emotional reactivity. Psychologically, this is typically the point at which children become more self-conscious and peer pressure ratchets up, so her possible lack of instinctive understanding of U.S. cultural norms, or her biracial makeup, may have become more salient, either in the form of an intrapsychic racial identity conflict or as an object of interpersonal bullying. It would be helpful to understand these details so as to attend to them in psychotherapy.
If she had begun middle school, academic pressure may have increased. However, her clinicians also should consider the possibility that one or both of her parents may have become stressed by the multiple cultural adaptations required by the move, or that the marriage had become strained, and that she responded to parental stress with increased anxiety. These are possibilities that need to be explored during the assessment.
Her ability to deal with her difficulties and finish high school speaks to her and her family’s resilience. To plan future treatment, it would be useful to explore what aspect of her treatment at age 10 was most helpful (medication, therapy, or both). Ideally, it would be helpful to understand the cultural elements of the relationship between the patient and the pediatrician and counselor. However, given her history, it is no surprise that when she is asked once more to navigate a new culture of college, this time without parental support, that her symptoms reoccur. If she is far from home, in a college where racial tensions are high or where there is not a large multiracial population, or if her parents are having trouble with empty nesting, this would make things more difficult. Her own cultural identity may have been challenged by an environment where she felt “no one understands her background and upbringing,” where “nobody noticed me,” and where “maybe they don’t like the way I look.”
How should clinicians explore these issues?
Erica’s clinicians should seek to understand how she herself defines her background, identity, and upbringing to help her examine possible conflictual issues that are causing distress. The DSM-5 Cultural Formulation Interview is a useful tool for achieving this goal, including its supplementary modules such as the one on Cultural Identity. As part of this assessment, her clinician could ask questions like: How does she see herself and how do other people see her in terms of her identity? How does she present herself? Is she being harassed on campus? Are any of these issues causes of her anxiety? Direct assessment of these topics is necessary to avoid initial impressions that might be affected by the clinician’s own identity, values, and biases. Her clinician should also be conversant in the stresses of the college environment, both at the intrapsychic and interpersonal levels.
While the usual treatments for anxiety, including cognitive-behavioral therapy and medications if necessary, may well be part of her clinical care, helping her understand her own personal cultural identity, how to negotiate the stresses of living on her college campus, and increasing both family and community supports are critical to her well-being and mental health.
While it is true that few people could exactly share Erica’s life experience, there are many pan-nationals and expats who would very much relate to her feelings. Erica faces many of the challenges of those in a group called “ third culture kids ,” a term coined in the 1950s by social scientists to describe the experience of children raised by Americans working in other countries. The expatriate lifestyle they described as an “interstitial culture” – different from but including elements of both the home culture and the host culture – often is specific to the work group (for example, military, business) that the adults were engaged in. For these children, the question of cultural identity, and “where is home,” is a complex one. For them, unlike their parents, the United States is not home but a foreign land. But their host country is not exactly home, either. Patients like Erica may benefit from reading “ Third Culture Kids: The Experience of Growing Up Among Worlds ,” by David C. Pollock and Ruth E. Van Reken, and clinicians would likely benefit as well.
Finally, Erica’s therapist could encourage her to find connections in the international student community; there are usually groups on campus for them, and they would understand a multicultural experience. Her therapist also should meet with, or speak with, her parents to see whether there are stresses at home, and could encourage them to support her by frequent visits or calls. When Erica finds a place where she feels at home, we believe her anxiety will decrease.
Key take-home points
1. Ask about, do not assume, the person’s own understanding of his/her background and identity to obtain more specific and precise information so as to guard against stereotyping that could lead to erroneous assessments.
2. Understand the heterogeneity of culture and the complexity of cultural identity.
3. Ask about the family. Who is in the family, both nuclear and extended? Draw a simple genogram . Envision and implement assessment beyond just the individual patient.
4. Assess the impact of culture change on cultural identity and family dynamics.
5. Use the DSM-5 Cultural Formulation Interview to help guide the cultural assessment.
Contributors
Ellen M. Berman, MD – University of Pennsylvania, Perelman School of Medicine, Philadelphia
Roberto Lewis-Fernández, MD – Columbia University and New York State Psychiatric Institute
Francis G. Lu, MD – University of California, Davis
The contributors have revised selected patient details to shield the identities of the patients/cases and to comply with HIPAA requirements. This column is meant to be educational and does not constitute medical advice. The opinions expressed are those of the contributors and do not represent those of the organizations they are employed by or those affiliated with GAP.
Resources
Diagnostic and Statistical Manual of Mental Disorders, 5th edition ( DSM-5 ). (Arlington, Va.: American Psychiatric Association Publishing, 2013).
Lewis-Fernández, R., et al. (eds.) DSM-5 Handbook on the Cultural Formulation Interview (Arlington, Va.: American Psychiatric Association Publishing, 2016).
Lim, R. (ed.). Clinical Manual of Cultural Psychiatry , 2nd edition (Arlington, Va.: American Psychiatric Association Publishing, 2015).
Pollock, D. and Van Reken, R. Third Culture Kids: The Experience of Growing Up Among Worlds (London: Nicholas Breasley Publishing, 2009).
Curbside Consult is inspired by the DSM-5’s emphasis on developing a cultural formulation of patients’ illnesses, and addressing family dynamics and resilience in promoting care that fosters prevention and recovery. We request that you submit cases to cpnews@frontlinemedcom.com in which your understanding and treatment are affected by challenging cultural and family issues. We will then write back with our best answers about how one might proceed in such a case. Your case and our response will be published in Clinical Psychiatry News. Please limit your case description to 250 words and include the following details:
1. Patient’s presenting problem or reason for the visit.
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3. Indicators of the patient’s identity – self-identified race/ethnicity, culture, religion/spirituality, socioeconomic status, education, among other variables.
4. Patient’s living situation, family composition, and genogram information (if available).
5. Patient’s geographic location (rural, suburban, urban) and occupation.
6. Patient’s and family’s degree of participation in their identified culture.
7. Questions of the individual submitting the case, including concerns about the role of the family and culture in the case, diagnosis, and treatment planning.
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